Introduction
COVID-19 has exacted a heavy toll on nursing home residents and their families across Ireland. Our sympathies go out to fellow service users who have suffered loss due to the pandemic. There is a feeling among some residents and their families that the nursing home system has failed them. The regulatory process is a key part of that system and we question whether the regulations in their present form and the arrangements for their enforcement are capable of protecting our relatives and friends in nursing homes and restoring an acceptable quality of life to these residential settings for the duration of the COVID-19 emergency and into the future. The existing regulatory system for Irish nursing homes, introduced in 2009, was the Government’s response to the Leas Cross scandal of 2005 and the regulatory failures exposed there. Sadly, it has taken the COVID-19 tragedy to focus attention on the necessity for an overdue root and branch reform in the sector.
The voice of residents and relatives
In spite of the traumatic events of 2020, it is remarkable that in none of the many official reports and comments on standards and oversight in nursing homes is there a mention of the service user as a stakeholder with a voice that should be heard. The work of the COVID-19 Nursing Homes Expert Panel is a case in point. Its report “Examination of measures to 2021”, which was published last August, has been described as clinical and technical but missing the human dimension, leaving the reader with no sense of how exactly COVID-19 restrictions have affected the wellbeing of residents and their families[1]. Equally, the HIQA review report entitled ‘The impact of COVID-19 on nursing homes in Ireland’ (published in July 2020) has not sought any objective input from residents or relatives.
Our experience of working in a voluntary capacity with the nursing home sector over the past 10 years has led us to the firm belief that a new framework for regulation in the sector, which will inevitably emerge from the COVID-19 tragedy in our nursing homes, must be built around the principle of meaningful service user participation in the process. This is necessary in order to ensure that service users are afforded due respect and that their voice is heard.
Recent experience, sadly, has demonstrated a paternalistic attitude to residents and their families and neither the HIQA nor the Expert Panel reports of recent months have done anything to correct that. Many service users are of the opinion that the State, its agencies and nursing home providers are still intent on talking for us rather than with us.This attitude comes across in the Expert Panel’s recommendations on visiting restrictions (Table 7.2: 11, 12 and 13), which are discussed merely in the context of end of life – and with strings attached. The Expert Panel urges ‘support and communication’ by nursing homes with residents and their families in order to ‘inform’ and ‘explain’ but does not encourage consultation with the service user. Both the Expert Panel and HIQA express empathy with distressed residents in their isolation but do not put forward concrete proposals to alleviate their circumstances.
The Joint Oireachtas Committee on COVID-19 Response published its report in October 2020. We reflect on that report, together with the HIQA and Expert Panel reports in the following pages. We are greatly encouraged by the energy, commitment and candidness of all three reports in their analysis of both COVID-induced and pre-existing weaknesses in models of support for older people, in the manner in which long-term residential care is organised and delivered and in the oversight regulations for the sector and their enforcement. The Nursing Home Quality Initiative (NHQI) will continue to monitor the direction of reform across the system and represent the views of residents and their relatives.
HIQA review report ‘The impact of COVID-19 on nursing homes in Ireland’ (July 2020)
NHQI commends HIQA on the support it has provided to our nursing homes and our relatives and friends who reside in them. Without question, its help and guidance were appreciated and of enormous help in seeing the sector through a time of unprecedented challenge and tragedy. HIQA’s July report acknowledges the dedication and sacrifice made by those employed in our nursing homes and acknowledges the stress and trauma endured by so many of them. NHQI wishes to associate ourselves with these sentiments and as service users, we acknowledge the debt of gratitude that is due to them.
HIQA review (What COVID-19 has taught us about nursing homes)
HIQA has drawn attention to many of the issues that the COVID-19 outbreak in nursing homes in Ireland has brought to the fore. Some nursing homes were unable to comply with the relevant regulations through a combination of poor governance and management, a lack of planning and outdated facilities and premises. It must be said that reports of weaknesses in leadership and management and the use of inadequate and unsuitable buildings are not new. All of these criteria, and more, have regularly featured in HIQA inspection reports and annual overview reports for many years. Our research has identified limitations in management and leadership competency in nursing homes as principal contributors to underperformance and regulatory non-compliance over many years. These findings have been corroborated in the annual overview reports of recent years. Yet, we are not aware of any steps taken to address gaps in the assessment or development of these competencies in our nursing home leaders. As a result of COVID-19, HIQA points to an urgent need for premises to modernise in order to facilitate physical distancing, promote proper infection prevention and control, and ‘provide residents with the dignity and privacy they deserve.’ The continued use of multi-occupancy rooms and outmoded premises in some nursing homes undoubtedly created conditions where the spread of infection was difficult to contain. HIQA suggests that it may be necessary to reduce occupancy levels in certain nursing homes to ensure that they are in a position to respond to any future outbreaks of disease. It is worth mentioning that the use of multi-occupancy rooms was originally due to have been phased out by 2015 but the deadline was extended to the end of 2021.
‘Gaps in clinical governance arrangements’:
HIQA explains that for many nursing homes the only form of clinical oversight is provided by general practitioners, and that this is insufficient for many homes given their size and the complex needs of residents. HIQA holds that nursing homes should be more closely integrated into community health programmes. HIQA also recommends that measures be introduced to ensure that health professionals would have access to up-to-date information on residents in order to ensure best possible care outcomes.
Staff skills and skill mix:
HIQA suggests that it may also be necessary to review and enhance staff skills and skills-mix to ensure that nursing homes have access to enhanced nursing staff as well as advanced nurse practitioners, such as those skilled in infection prevention and control or care of the elderly. We go further. We strongly hold that such enhancement is essential, that State sponsorship of staff development initiatives is a must and that a much more robust oversight of staff-related matters is required.
Strengthening the regulations:
HIQA calls for a strengthening of the regulations governing nursing homes that have been in place since 2013. We agree. However, we hold that the enforcement structures which have remained largely unchanged since 2009 also need to be revisited after more than eleven years in operation, especially in the light of the intense challenges facing the sector into the future.
The health and wellbeing of service users
In addressing the ongoing threat of COVID-19 and what it means for nursing homes, HIQA anticipates that nursing homes will continue to look different in terms of their physical environment, visiting arrangements, social activities and care practices. There is no question but that COVID-19 has caused much anxiety, grief, fear and isolation for residents, their families, friends and carers. HIQA have committed to working with nursing home providers to ensure that new measures ‘strike the correct balance between keeping people safe and promoting a good quality of life.’ However, as a relatives’ group, we are disappointed to note that no specific proposals for achieving that balance have been put forward. We are reminded that HIQA is the singular expert body closest to nursing homes and holding in its possession an infinite store of knowledge of the strengths, weaknesses and potential for change at each and every nursing home on the register.
HIQA say that meaningful and comprehensive engagement with residents and their advocates is imperative to ensure that the lessons of this public health emergency are learned and that they will continue to listen to the experiences of residents and service providers to strive for safer, better care that focuses on the human-rights and individual needs of the person. NHQI looks forward to being a party to this dialogue with HIQA, nursing home providers and other stakeholders.
NHQI cautions that there are more deep-seated, more fundamental challenges in the nursing home sector than those thrown up by an unprecedented global pandemic. Some of these we have touched upon already. Others, such as lack of expertise in dementia care (referred to elsewhere on this site: c.f. Suzanne Cahill article), evidence of outmoded ‘institutional’ culture and practices and slow buy-in to the principles of person-centred care and quality of life. In HIQA’s words, after years of moving towards a more homely, social model of care, the pandemic meant the rapid re-introduction of the medical model of care. This statement, as it stands, concerns us. We see this development not as an inevitable consequence of the pandemic but as a challenge to be met with courage and imagination by the nursing home provider community, the regulator and the State. The first step is to acknowledge the potentially devastating impact of isolation, social deprivation and loneliness on the general health and wellbeing of nursing home residents and the stress and loss endured by their families. NHQI is ready to engage with legislators, regulators and providers on all of these matters.
COVID-19 Nursing Homes Expert Panel – Examination of Measures to 2021(Reported August 2020)
We at NHQI have studied closely the work of the Expert Panel and we were pleased to make a submission to the Panel in response to its public request for input from interested parties.
The Expert Panel conducted a comprehensive investigation into multiple aspects of the pandemic as it affected nursing home residents and staff. In compliance with its terms of reference[2] the Panel described its task as[3]
forward-looking to protect the at-risk population in nursing homes into the near future, whether or not a surge of COVID-19 occurs or if the infection remains in the community and continues to be a risk to those especially vulnerable to it. The Panel’s work was… to identify those lessons learned but to seek to apply these insights in a tighter timescale in order to improve the outcome of the ongoing response.
The Panel reports a comprehensive list of recommendations, identifies those parties with primary responsibility for following through on each recommendation together with timeline targets in each case. There are 86 recommendations in all, ranging across the 15 thematic areas below: 1) Public Health measures; 2) Infection prevention and control; 3) Outbreak management; 4) Future admissions to nursing homes; 5) Nursing home management; 6) Data analysis; 7) Community Support Teams; 8) Clinical – general practitioner lead roles on Community Support Teams and in nursing homes; 9) Nursing home staffing & workforce; 10) Education; 11) Palliative care; 12) Visitors to nursing homes; 13) Communication; 14) Regulations; 15) Statutory care supports.
The Government has moved swiftly to endorse the findings of the Expert Panel and to put structures in place for their implementation. An inter-agency Implementation Oversight Team has been set up and other supporting structures put in place. NHQI will monitor progress ongoing in this crucial implementation phase.
Oireachtas Committee Report on COVID-19 Response October 2020
NHQI has followed with keen interest the proceedings of the Joint Oireachtas Committee on the COVID-19 Response. The Committee asserts that despite several meetings and having listened to a multitude of witnesses, it was unable to get satisfactory answers as to why 985 residents of nursing homes died after they contracted COVID-19. The Committee examined the reports from HIQA and the Expert Panel, already referred to here which the Committee says highlight some of the systemic weakness in our care of the elderly. They also note a silo type approach on the part of the State that did nothing, in their view, to prevent the spread of the disease. From the evidence collected, the Committee forms a number of conclusions, for example, the early focus of public health authorities on the state of preparedness of acute hospitals and slower reaction to a deteriorating situation in nursing homes. Acknowledging the ‘Trojan efforts’ made by nursing home staff, the Committee was left with unanswered questions as to why some nursing homes were free of COVID-19 whereas others were severely impacted through the death of residents and the sickness levels of staff.
The Committee noted that there had been a failure to provide answers to the relatives of those who died and that this had exacerbated their pain and suffering. Their first recommendation is that a public inquiry be established to investigate and report on all circumstances relating to each individual death from COVID-19 in nursing homes. The Committee also calls for a review into the impact of privatisation of Ireland’s nursing homes and lists ‘systemicweaknesses’ in the provision of services, in the regulation of service provision and in the protection of employees that resulted in a poorer outcome for many individuals, such as residents in nursing homes and low paid workers. The Committee finds that many of these issues were known about for many years but were not addressed or were being addressed at too slow a pace.
The Oireachtas Committee calls for the phasing out by the State of support for facilities where residents do not have adequate self-isolation facilities, ensuring that all residents can live in self-contained units and that future provision of older person long-term care is provided in smaller units within the public system in order to ensure strong clinical governance, quality and accountability. The Committee also finds that the State is over reliant on institutional care for our vulnerable population, a matter highlighted by the Expert Panel report. The Committee has welcomed the blueprint for the care of the elderly put forward by the Expert Panel. The Committee asserts that future moves to support older people at home must have, as a priority, a publicly funded and publicly provided model of care that is underpinned by community intervention teams from the HSE. The Committee identifies a number of systemic issues that it finds led to poor outcomes for residents. These are reproduced in full here:
a. The failure to upgrade homes leading to a situation where sick residents could not be isolated and were sharing bedrooms and bathrooms, thus contributing to the spread of the virus.
b. The ongoing decisions being made by the HSE to place residents in nursing homes that have regulatory compliance issues, especially with regard to infection control.
c. The lack of a proper framework relating to the number and skills capacity of health care workers in nursing homes. The State has left this to the discretion of the owners of nursing homes, 80% of which are now in the private sector.
d. The delay in reviewing the adequacy of the regulatory framework for nursing home care, an issue that was highlighted by HIQA over a number of years.
e. The absence of a clinical oversight and care pathways between nursing homes and the public health authorities.
f. The failure to invest in acute and step-down hospital bed capacity which led to the State having to transfer over 10,000 patients into long-term residential care settings, including nursing homes, in order to prepare hospitals for the potential arrival of members of the public requiring acute care having contracted the virus. Not all of those who were transferred out needed to go into institutional care.
g. The lack of a coherent policy on the care of older people which, through the provision of tax incentives, has seen the continuation of long-term institutional care in large settings where ownership has flipped from the public to the private sector over the past 30 years.
h. A policy of privatisation of the nursing home sector that was disconnected from the public health system without due debate or consultation.
i. The failure to prioritise empowering older persons to remain at home and develop models including smaller domestic-style units integrated into towns and city community areas.
The Oireachtas Committee calls for urgent steps to be taken for the implementation of the recommendations of the Report of the COVID-19 Nursing Home Expert Panel with regular progress reports to the Houses of the Oireachtas. NHQI has noted earlier in this paper that implementation structures are already in place under the leadership of the Department of Health and that we will monitor their progress. The Committee recommends that standards regarding staffing and staff ratios in nursing homes be developed by HIQA. It also recommends that the Government make provision for a statutory sick pay scheme to cater for low paid workers such as those in nursing homes. NHQI welcomes these proposals.
The regulatory framework
In highlighting the need for stronger regulation, the Committee examines the role of the State, which it notes can inhibit the effectiveness of regulations by not providing appropriate staffing levels to regulators. The Committee also notes the Expert Panel’s concern about changes made to two key HIQA regulations which revoked (i) the requirement for the ‘person in charge’ of a nursing home to have a formal gerontology qualification and (ii) the requirement for the presence of a registered nurse on duty at all times. NHQI agrees that these requirements should be restored. The Committee goes on to say that incidences of non-compliance with regulations can no longer be deemed compatible with a business as usual model. It recommends an urgent review of the regulatory frameworks and calls on the relevant Ministers to report to the Houses of the Oireachtas on the outcome of that review by the end of 2020. NHQI will follow these developments closely.
Concluding comment
The Oireachtas and Government, together with the relevant public bodies, medical services and academics have committed heavily to the management of and recovery from the COVID-19 pandemic. In relation to nursing homes, our sympathies go out to fellow service users who have suffered loss due to the pandemic. Looking to the future, services and processes as well as regulatory oversight have all been subjected to rigorous forensic analysis and shortcomings have been identified. These must now be addressed without delay and in a spirit of collaboration with stakeholders. This time around, the involvement of service users is an imperative and NHQI stands ready to participate in dialogue.
[1] Dr Suzanne Cahill, Irish Times 24 August 2020
[2] Terms of reference of Expert Panel
• provide assurance that the national protective public health and other measures adopted to safeguard residents in nursing homes, in light of COVID-19, are appropriate, comprehensive and in line with international guidelines and any lessons learned from Ireland’s response to COVID-19 in nursing homes to date;
• provide an overview of the international response to COVID-19 in nursing homes utilising a systematic research process;
• report to the Minister for Health by end June 2020 in order to provide immediate real-time learnings and recommendations in light of the expected ongoing impact of COVID-19 over the next 12-18 months.